Anastomotic Strictures After Roux-en-Y Gastric Bypass: a Cohort Study from the Scandinavian Obesity Surgery Registry

Endoscopic therapies for bariatric surgery complications

PURPOSE OF REVIEW

The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications.

RECENT FINDINGS

The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB.

SUMMARY

Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.

Comparative analysis of linear- and circular-stapled gastrojejunostomies in Roux-en-Y gastric bypass: a focus on postoperative morbidity using the comprehensive complication index

PURPOSE

The linear-stapled (LSA) and the circular-stapled anastomosis (CSA) are the two most commonly performed techniques for the gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (RYGB). This study compared the outcome after both techniques with special focus on postoperative morbidity using the comprehensive complication index (CCI).

METHODS

Five hundred eighty-eight patients operated between 01/2010 and 12/2019 were included in the final analysis and divided in two cohorts according to the surgical technique of the GJ (LSA (n = 290) or CSA (n = 298)). Before 09/2016, the CSA was exclusively performed for the GJ, while after 09/2016, the LSA was solely used.

RESULTS

The mean CCI for patients with Clavien-Dindo complication grade ≥ 2 within the first 90 days after RYGB was 31 ± 9.1 in the CSA and 25.7 ± 6.8 in the LSA group (p < 0.001), both values still below the previously published benchmark cutoff (≤ 33.73). The C-reactive Protein (CRP)-levels on postoperative days (POD) 1 and 3 as well as the use of opioids on POD 1 were significantly higher in the CSA- than in the LSA-group (all p < 0.001). There were significantly more internal herniations in the CSA group during the first 24 postoperative months (p < 0.001).

CONCLUSION

Patients after RYGB with CSA were found to have higher CCI values during the first 90 PODs compared to patients in which the LSA was applied. To achieve optimal outcomes in terms of patient morbidity, the LSA seems to be the superior technique for GJ in RYGB.

The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic

Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.

Endoscopic Management of Surgical Complications of Bariatric Surgery

Bariatric surgery, although highly effective, may lead to several surgical complications like ulceration, strictures, leaks, and fistulas. Newer endoscopic tools have emerged as safe and effective therapeutic options for these conditions. This article reviews post-bariatric surgery complications and the role of endoscopy in their management.

Hand-Sewn Gastrojejunostomy In Situ to Solve Acute Anastomotic Stricture Due to Submucosal Tunneling in Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is the second most widely used bariatric surgical procedure for morbid obesity and its related comorbidities. Anastomotic stricture is one of the major complications after RYGB. Submucosal tunneling is a rare cause of anastomotic stricture or occlusion, and clinical symptoms will appear soon after surgery. We present our technical suggestions to perform a hand-sewn gastrojejunostomy in situ when the gastric pouch is too small and the tissue is not enough to be resected to solve acute anastomotic stricture due to submucosal tunneling in gastric bypass.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (&gt; 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Incidence and risk factors for early gastrojejunostomy anastomotic stricture requiring endoscopic intervention following laparoscopic Roux-en-Y gastric bypass: a MBSAQIP analysis

BACKGROUND

Gastrojejunostomy (GJ) stricture is one of the most commonly recognized complications following laparoscopic Roux-en-Y gastric bypass (LRYGB). The risks involving the formation of early GJ stomal stenosis are largely unknown. The aims of this study are to evaluate the rate and risk factors associated with GJ stricture in patients requiring esophagogastroduodenoscopy (EGD) within 30 days after LRYGB.

METHODS

This is a retrospective study of patients who underwent EGD for GJ stricture following LRYGB. Data were retrieved from MBSAQIP database from 2015 to 2018. Descriptive, bivariate, and logistic regression analyses were performed. Those who had reoperation, readmission, and intervention for other indications rather than GJ stricture were excluded from the risk factor analysis.

RESULTS

760,076 patients underwent bariatric surgery. Of these, 184,660 (24.3%) underwent LRYGB and 875 had GJ stricture within 30 days postoperatively. The overall incidence of early GJ stricture after LRYGB was 4.7 per 1000 person-years. The incidence decreased from 6.2 to 3.4 per 1000 person-years during the 4-year period. 85% of patients with GJ stricture required therapeutic intervention. Median (IQR) day to the first endoscopic intervention was 25 (21-28) days. The overall 30-day readmission rate was 40%. 30-day reoperation rate due to GJ stricture was 5.6%. No 30-day mortality occurred. Factors independently associated with an increased risk for early GJ stricture include concurrent hiatal hernia repair (Adjusted Odds Ratio-AOR 1.8, 95% CI 1.5-2.2), revision case (AOR 1.4, 95% CI 1.1-1.6), African American (AOR 1.4, 95% CI 1.2-1.7), gastroesophageal reflux disease-GERD (AOR 1.4, 95% CI 1.2-1.5), drain placement (AOR 1.3, 95% CI1.1-1.4), and routine postoperative swallow study (AOR 1.3, 95% CI 1.1-1.50).

CONCLUSION

The incidence of early GJ stricture following LRYGB decreased at MBSAQIP-accredited centers over the review period. Patients having additional manipulation at or around GJ were at risk of developing early GJ stricture after LRYGB.

Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration

PURPOSE

Marginal ulceration (MU) is a common long-term complication following Roux-en-Y gastric bypass (RYGB). The causes of MU after RYGB are multifactorial and include surgical technique of constructing the gastrojejunal anastomosis (GJA). The purpose of this study is to evaluate the relationship between gastric pouch size in RYGB and MU using CT volumetrics.

MATERIAL AND METHODS

Patients were retrospectively identified who underwent esophagogastroduodenoscopy (EGD) following RYGB at a tertiary care teaching hospital. Measurement of gastric pouch size was performed using 3-D CT software. Standard statistical methods were used, a univariate comparison was performed between MU and non-MU patients followed by a propensity-matched comparison to control for factors known to affect MU, and a propensity-matched subgroup analysis was also performed.

RESULTS

In total, 122 patients met criteria, 57 of which had MU on EGD and 65 who did not. The MU group had more smokers and patients with PPI use than the non-MU group, and the mean time from operation to CT scan was 26.6 months (range: 0-108 months). The MU group had a larger gastric pouch size than the non-MU group (34.1 ± 11.8 versus 20.1 ± 6.8 cm³). When analyzed for matched patient cohorts, this difference remained for the MU group that included smokers and PPI use. When stratified for pouch size, for each 5 cm³ increase in pouch size, patients had 2.4 times odds increase of MU formation.

CONCLUSIONS

CT volumetric analysis demonstrated that a larger gastric pouch size was associated with MU following RYGB.

Banded RYGB Ring Slippage Endoscopic Removal with Self-expandable Stents: a Comparative Study Between Metallic and Plastic One

PURPOSE

Banded Roux-en-Y gastric bypass (RYGB) was a common bariatric procedure in the 2000s, and the ring slippage is one of its late adverse events. Both plastic and metallic stents have been reported as adjunct methods to induce erosion and facilitate endoscopic removal of the ring.

OBJECTIVE

To compare the safety and effectiveness of self-expanding metallic stents (SEMS) and plastic stents (SEPS) to treat ring slippage.

MATERIALS AND METHODS

We conducted a retrospective longitudinal study analyzing consecutive patients with ring dysfunction treated with stents plus endoscopic removal.

RESULTS

Ninety patients were enrolled (36 SEMS vs. 54 SEPS). The mean age was 48.56 ± 13.07 and 45.6 ± 12.1 in the SEMS and SEPS groups, respectively. All patients had band slippage, but 24 from SEMS group and 23 from SEPS group had further complications. There were more complications in metallic stent concerning mean absolute number of therapy-related adverse events (1.33 ± 0.48 vs. 1.72 ± 0.5, p > 0.05) and time until erosion (14.9 ± 1.6 vs. 13.8 ± 1.4 days, p > 0.05). Female sex and age > 41 years old correlated with longer time to band erosion and higher incidence of adverse events in SEMS patients. In SEPS group, only female sex was a risk factor for adverse events.

CONCLUSION

Both procedures were efficient at inducing band erosion with similar safety profiles. Older and female patients are at a higher risk of treatment-related adverse events, especially those receiving SEMS.

Preoperative high-resolution esophageal manometry and postoperative symptoms in patients undergoing bariatric surgery: a retrospective cohort study

BACKGROUND

The increasing incidence of obesity has led to a rise in bariatric surgeries. Obesity can be associated with various gastrointestinal symptoms as well as abnormal findings on high-resolution esophageal manometry (HRM). Bariatric procedures have variable effects on esophageal function and may contribute to postoperative symptoms. Preoperative HRM is not performed routinely on patients undergoing bariatric surgery but may identify patients likely to experience postoperative esophageal symptoms via delineation of structural or functional abnormalities.

OBJECTIVES

To evaluate whether prebariatric surgery HRM could predict persistent or de novo postoperative esophageal symptoms.

SETTING

Academic tertiary care hospital, United States.

METHODS

Retrospective data were collected for 20 patients undergoing HRM and 100 controls 18 years and older from May 2012 to May 2015. Propensity score matching was performed to adjust for baseline differences between the 2 groups. Preoperative and postoperative esophageal symptoms (reflux, dysphagia, nausea/vomiting, bloating, fullness, early satiety, pain, and intolerance) were compared between HRM and control patients, and associations among HRM findings, Chicago Classification, and symptoms were analyzed. All included patients had follow-up beyond 3 months postoperatively. Data were analyzed with 2-tailed Fisher's exact test, Wilcoxon rank-sum test, and odds ratio.

RESULTS

Compared to controls, patients undergoing preoperative HRM had a higher rate of postoperative chronic intolerance (25% versus 8%, P = .041). This difference was not observed in propensity score matching analysis. Identification of elevated integrated relaxation pressure and esophagogastric junction outflow obstruction predicted chronic intolerance (odds ratio = 21.0; 95% confidence interval: 1.40-314; P = .027 for each).

CONCLUSIONS

Preoperative HRM abnormalities were associated with postoperative symptoms in patients undergoing bariatric surgery. HRM can identify patients who are more likely to experience postoperative esophageal symptoms and may aid in discussion of suitability for surgery and selection of bariatric intervention.

Transoral outlet reduction: could additional sutures cause more harm?

BACKGROUND

The double purse-string pattern (DPSP) of transoral outlet reduction (TORe) should conceivably result in a more robust scaffolding for the gastrojejunal anastomosis (GJA). However, there is a paucity of literature pertaining to post-TORe stenosis as an adverse event. Our aim was to determine the rate of stenosis, its potential predictors, and other complications of DPSP TORe.

METHODS

We performed a retrospective analysis of a prospectively maintained database of 129 consecutive patients who underwent DPSP TORe between December 2015 and August 2019.

RESULTS

The adverse event rate of TORe was 17.1 % (n = 22), with a 13.3 % (n = 17) rate of stenosis. Stenosis was not significantly associated with any baseline characteristics. GJA diameter pre- and post-TORe, the difference between these values, and procedure duration were not predictive of stenosis. Of patients who developed stenosis, 10 (58.8 %) responded to endoscopic balloon dilation and 7 (41.2 %) required stent placement.

CONCLUSION

As the DPSP technique is a challenging procedure, with high complication rate and limited benefit, it should not be used for TORe.

Re-do Laparoscopic Gastrojejunostomy for Gastrojejunal Anastomosis Stricture After Roux-en-Y Gastric Bypass

Stricture of the gastrojejunostomy is a possible complication after laparoscopic Roux-en-Y gastric bypass. We present the case of a patient with stricture refractory to endoscopic dilation. The patient underwent laparoscopic revision of the gastrojejunostomy with a hand-sewn anastomosis.

Gastrojejunal Anastomotic Stricture Following Roux-en-Y Gastric Bypass: an Analysis of Anastomotic Technique at a Single Institution

PURPOSE

Patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) are at risk of developing strictures of the gastrojejunal anastomosis (GJA). Several variables can affect this, one of which may be the method of anastomosis. Between 2010 and 2014, our institution utilized three different anastomotic techniques for creating the GJA (25 mm end-to-end circular-stapled (CS), linear-stapled (LS), and robotic hand sewn (HS)). Our objectives were to compare the method of GJA relative to the subsequent development of anastomotic stricture.

METHODS

We queried our electronic health record for all patients who underwent an upper endoscopy (EGD) after RYGB (2010-2014). Patient charts were retrospectively reviewed for type of GJA, weight loss, complications, interventions, and revisions of the GJA.

RESULTS

In total, 1112 RYGB were performed at our institute, and 17.4% of patients (194/1112) had an upper endoscopy (EGD). Overall, 3.1% (34/1112) were found to have a stricture of the GJA. Patients undergoing a CS, LS, and HS anastomosis had GJA stricture rates of 4.9%, 0.5%, and 1.2% respectively (CS to LS (p < 0.05), p = NS among CS vs. HS, and LS vs. HS). The rate of GJA revision was 1.5%, 0.5%, and 0.1% (p = NS). In patients who had an EGD, excess BMI loss was 57.4%, 64.6%, and 59.2% (p = NS). In patients symptomatic from strictures, excess BMI loss was 69.4%, 83%, and 63.5% respectively (p = NS).

CONCLUSION

The anastomotic technique for creating of the GJA may impact the formation of strictures. Based on our experience, gastrojejunostomies created with a 2-mm EEA-stapling technique are at higher risk of strictures.

Treatment of refractory benign gastroenteral strictures with fully covered metal stents

Video 1Treatment of refractory benign gastroenteral strictures with fully covered metal stents.

Clinical and Endoscopic Predictors of Hydrostatic Balloon Dilation Failure for Post-Bariatric Anastomotic Stricture Treatment

BACKGROUND

Roux-en-Y gastric bypass (RYGB) patients can develop anastomotic strictures. The initial management relies on endoscopic hydrostatic balloon dilation, but in a subset of patients, it may be unsuccessful despite several dilations, requiring a different treatment modality. We evaluated the factors associated with balloon dilation failure and need for revision surgery.

METHODS

Retrospective analysis from patients presenting with a post-RYGB anastomotic stricture who underwent balloon dilation from 2005 to 2018 at Cleveland Clinic Florida and Cleveland Clinic Main Campus. Demographic, clinical, surgical, endoscopic, and post-procedural variables were collected. Univariate and multivariate analysis with odds ratio (OR) and 95% confidence interval (95% CI) calculation for factors associated to dilation failure was performed.

RESULTS

Eighty-nine patients were included in the analysis. Population was predominantly white (85.4%) and female (87.6%), with mean age 46.4 years and followed for a mean of 97.4 months. All patients presented dysphagia, with mean stricture diameter of 7.7 mm and associated marginal ulcer in 69%. Successful dilation was achieved in 65 patients, while 24 patients had dilation failure and underwent revisional surgery. Multivariate analysis showed a higher risk of dilation failure if time from RYGB to first dilation was >3 months (OR 4.95, 1.29-19.04; p = 0.02), and if nausea/vomiting were present before first dilation (OR 4.37, 1.11-17.16; p = 0.03). One patient had a perforation after dilation and was treated surgically.

CONCLUSIONS

Post-RYGB anastomotic strictures can be successfully treated with hydrostatic balloon dilation. However, patients with dilations performed > 3 months after initial RYGB and nausea/vomiting have an increased risk of dilation failure and need for further interventions.

Comparison of gastrojejunostomy techniques and anastomotic complications: a systematic literature review

BACKGROUND

There are several ways to perform the gastrojejunostomy (GJ) anastomosis in laparoscopic Roux-en-Y gastric bypass (LRYGB). Surgeons typically use a variation of three techniques: Hand-sewn anastomosis (HSA), Linear stapled (LS) and Circular stapled anastomosis (CSA). The purpose of this literature review is to determine which of the GJ techniques, if any, is superior and results in the least amount of postoperative complications, with a specific focus on rates of marginal ulcers, postoperative bleeding, and strictures.

METHODS

PubMed, Embase, and Cochrane electronic databases were consulted for studies on LRYGB procedures utilizing a GJ anastomosis, from January 1, 2015 to December 31, 2019. Cochrane and PRISMA screening methods were used to select the studies.

RESULTS

Eleven studies published between 2015 and 2019 were selected and included 135,899 patients that underwent LRYGB with a GJ anastomosis. Sample sizes ranged from 114 to 49,331 patients. Four studies reported that CSA had statistically significant higher rates of marginal ulcers when compared to HSA and LS techniques. Three studies concluded that CSA had statistically significant higher rates of postoperative bleeding when compared to HSA and LS. Five studies observed that CSA had statistically significant higher rates of strictures when compared to HSA and LS techniques. There was no consensus whether HSA or LS was superior in terms of reduced postoperative complications.

CONCLUSION

This study revealed statistically significant increases in rates of postoperative bleeding, marginal ulcer, and strictures with the use of mechanical circular staplers at the GJ anastomosis in LRYGB. Based on our results, avoiding the use of mechanical circular staplers can result in fewer postoperative complications. Nevertheless, there are limitations to retrospective studies which may influence the results and therefore a randomized controlled trial directly comparing HSA, CSA, and LS should be performed to truly determine which technique is superior.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Management of Esophageal Achalasia after Roux-en-Y Gastric Bypass: Narrative Review of the Literature

INTRODUCTION

The development of achalasia after Roux-en-Y gastric bypass (RYGB) is rare. Heller myotomy (HM) is the gold standard treatment while peroral endoscopic myotomy (POEM) is an emerging technique with promising results. The aim of this narrative review was to summarize the current knowledge on the treatment of esophageal achalasia after RYGB.

METHODS

PubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of achalasia after RYGB were included in this narrative review.

RESULTS

Twelve studies for a total of 28 patients were included. The age of the patient population ranged from 44 to 70 years old and 80% were females. Overall, 61.5% underwent laparoscopic RYGB while 38.5% underwent open RYBG. The elapsed time from the RYGB to myotomy ranged from 14 months to 14 years. Dysphagia (64%) and regurgitation (60.7%) were the most commonly reported symptoms; type I achalasia was diagnosed in 50% of patients. Surgical HM was performed in 17 patients (61%) while POEM was performed in 11 patients (39%). Postoperative morbidity was 3.6% with no differences comparing surgical HM and POEM (6% vs. 0%, p = 0.43). The follow-up time ranged from 1 to 43 months. The overall recurrence rate requiring reoperation was 7% with no differences comparing surgical HM and POEM (12% vs. 0%; p = 0.25).

CONCLUSION

Both HM and POEM seem feasible, safe, and effective in the management of achalasia after RYGB. The role of POEM in the management algorithm of these patients should be further evaluated.

Value of robotic-assisted technique in redo gastrojejunostomy for severe stenosis after gastric bypass

Development of gastrojejunal stricture following Roux-en-Y gastric bypass (RYGB) leads to an increase in morbidity and adverse effects, such as abdominal pain, vomiting, aspiration pneumonia, and malnutrition. Up to 38.5% of patients will require revisional surgery for late anastomotic strictures despite conservative treatment. However, no previous studies focused on revisional robotic bariatric surgery due to strictures after RYGB have been reported. To evaluate our outcomes and assess the advantages of the robotic platform with regard to laparoscopic and open revisional procedures. University Hospital. We performed a retrospective analysis of patients who underwent laparoscopic robotic-assisted redo gastrojejunostomy from 2016 to 2018. Demographics, surgical data, medical treatments, postoperative outcomes, and adverse effects were collected. Nine patients with symptomatic anastomotic strictures after primary RYGB underwent robotic revisional surgery. All patients received medical therapy as a first approach, and five patients (55.5%) underwent endoscopic balloon dilation. All procedures were successfully completed with robotic assistance, with a mean (standard deviation) operative time of 184.5 (49.1) min, and no intraoperative adverse effects were registered. Median (range) hospital stay was 2 (1-4) days. One patient presented with a postoperative intra-abdominal abscess and was treated with intravenous antibiotics and image-guided drainage. No anastomotic leak, hemorrhage, or mortality were reported. Robotic assistance seems to be safe and effective for redo gastrojejunostomy secondary to stricture. Even though the sample size is small, we believe that the application of robotic techniques may provide advantages and improve the outcomes in these complex revisional procedures.

Mechanical factors in the prediction of integrity of the gastrojejunal anastomosis in ex-vivo RYGB models

BACKGROUND

Surgical staplers represent one of the important instruments in modern surgery. Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric procedures. Various techniques have been described for performing gastrojejunal (GJ) anastomosis, including linear stapled anastomosis (LSA), circular stapled anastomosis (CSA) and hand-sewn anastomosis (HSA).

OBJECTIVES

An ex-vivo porcine-based experiment was designed to compare the mechanical integrity of the GJ anastomosis among the 3 different techniques by measuring burst pressure (BP).

SETTING

Laboratory-based study conducted at the clinical skills laboratory at Birmingham Heartlands Hospitals, Birmingham, United Kingdom.

METHODS

Porcine stomachs and small bowels were used to create a GJ model. Four GJ anastomosis models each were created using circular stapler (CSA group) and hand-sewn techniques (HSA group). Stomach and small bowel thickness were recorded. BP was measured by sequential injections of methylene-blue diluted saline until a leak was detected. Total volume until leak is recorded. Compliance (C) was calculated using the formula C = ΔP/ΔV.

RESULTS

Results from our previous experiment for the LSA group are included. One model was excluded from the CSA and the HSA groups due to technical errors. Results were presented as mean ± standard deviation. Total volume in LSA, CSA, and HSA groups was 60 ± 4.08 mL, 73.67 ± 3.22 mL, and 51.67 ± 20.21 mL, respectively. BP in LSA, CSA, and HSA groups was 18 ± 4.69 mm Hg, 20.33 ± 5.77 mm Hg, and 9.67 ± 3.79 mm Hg, respectively. There was a statistically significant difference in BP among the 3 groups (P = .033; Kruskal-Wallis test). C in LSA, CSA, and HSA were 3.50 ± .88 mm Hg/mL, 3.78 ± .85 mm Hg/mL, and 5.39 ± 1.34 mm Hg/mL, respectively (P = .064).

CONCLUSION

BP was higher in CSA and LSA groups compared with the HSA group, suggesting a mechanically stronger anastomosis. Despite the lack of statistical significance, higher BP recorded in the CSA group than in the LSA group suggests better anastomotic integrity.